Emergency Doctor Worries Louisiana’s New Classification for Abortion Meds Could Be Life-Threatening

A new law will go into effect in Louisiana on Oct. 1 that will classify two drugs—mifepristone and misoprostol, which are commonly used for abortions, postpartum hemorrhaging, and miscarriage management—as “controlled dangerous substances.” The change is worrying doctors who say the repercussions could be life-threatening for some.

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The law, which passed in the state House and Senate in the spring and was shortly after signed by Republican Gov. Jeff Landry, makes Louisiana the first state in the country to reclassify the medications. While abortion is banned in nearly all circumstances in Louisiana, the drugs have many other medical uses, and doctors have argued that reclassifying the medications could restrict or block patients’ access to health care, sometimes in emergencies.

The bill, known as SB 276, was initially only about criminalizing the administration of these drugs to a pregnant person without their knowledge or consent, but the move to reclassify the two drugs was added as an amendment to the bill late in the legislative process. Under the new law, the drugs will be categorized in the same vein as Valium and Xanax.

An anti-abortion group, Louisiana Right to Life, worked on the bill and amendment. Before it passed, more than 200 Louisiana doctors signed a letter to lawmakers objecting to the amendment. Research has found both medications to be safe, and the U.S. Food and Drug Administration doesn’t consider the drugs to have a significant risk of abuse or dependence.

Sarah Zagorski, communications director for Louisiana Right to Life, says that while she understands the concern, the state has offered “plenty of guidance and clarification” that make it clear that the drugs can be used in medically necessary situations. She cites the Louisiana Department of Health, which released guidance for health care professionals in September, saying that the drugs can be used to treat postpartum hemorrhage and incomplete miscarriages and should be “securely stored” in a “locked/secured cabinet, compartment, or other system.” But obtaining access to locked medications in emergency situations is concerning for physicians.

Dr. Jennifer Avegno, director of the New Orleans Health Department and an emergency medicine physician who co-wrote the objection letter to lawmakers in the spring, says there are still a lot of unanswered questions and concerns. TIME interviewed Avegno about how health care professionals are preparing for the new law—and the fears they have about it.

This interview has been condensed and edited for clarity.

What are your main concerns about the law?

The one that’s been coming up the most in the last couple of weeks is on the inpatient side. Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, as well as in America. I will say that Louisiana has made great strides in reducing postpartum hemorrhage because they’ve worked very, very hard on instituting evidence-based practices across the state, and one of those is what’s known as a safety bundle—sort of a national standard for how you should care for postpartum hemorrhage.

In that safety bundle, it says that medications to treat postpartum hemorrhage should be immediately available. That’s what’s happening now. Misoprostol is a first-line medical treatment for hemorrhage. It is very easy to administer. It also works pretty quickly, and it has fewer contraindications than the other medications. It also doesn’t have as many side effects.

As it stands now, most hospitals have the ability to have that misoprostol right at the bedside in an open cart so that the patient can get it as soon as possible. What happens on Oct. 1 in Louisiana is that, because it is a controlled substance, it is now governed by all of the restrictions on controlled substances, which in Louisiana means it has to be stored away from other medications in what they describe as a securely locked, substantially constructed cabinet.

It’s a very specific type of place that the medication is locked—you have to have authorization and a special procedure for getting in; you have to have a distinct order for that patient. You can’t just go pull it or have it on a cart and pop it in. And those cabinets are not mobile, so you might be on the labor and delivery floor, and there’s 15 rooms on that floor, and that cabinet is somewhere down the hall, which means you’re now going to have to send a nurse from the bedside of a patient who is deteriorating to go do all the things that need to be done for a controlled substance and come back. People are like, “Well, what’s a couple of minutes?” As someone who treats emergencies all the time, minutes matter. And if you’ve ever watched a woman bleed out after childbirth, it is not something that you have the luxury of time to deal with.

It’s the standard of care in America to have these medications immediately available. A lot of doctors are very, very concerned about this. They’ve been doing drills to see how much longer it is going to take. And it definitely does add several minutes on—and that’s when everything goes right. We’ve asked for clarification if there’s any other way that this medication could be immediately available. We haven’t received it yet.

On the outpatient side, there’s a lot of concern about prescriptions not being filled. We have communicated to our providers in our learning session [about the law] that you have to put a diagnosis code on the prescription, whereas for other medications you might not. A lot of the official diagnosis codes for miscarriage include the word abortion in it—it’s a “missed abortion.” Those are medical terms. Those mean miscarriage, for all intents and purposes. But we have heard from pharmacists that are concerned about some of their colleagues saying, “I don’t want to fill anything that says ‘abortion’ on it. I don’t want to go to jail because some thinks I’m aiding and abetting an elective termination.”

There’s a lot of things that go into filling a controlled-substance prescription that’s different from a regular prescription, and there’s real concern that folks aren’t going to be able to get their prescriptions. If you can’t manage your miscarriage medically, then there’s more discomfort and potential for complications. You may have to have a surgical procedure that maybe you wouldn’t have needed or didn’t really want.

Then we’ve heard from providers who are concerned because one of the uses of misoprostol is to facilitate procedures—things like IUD insertion or doing a scope into the uterus for bleeding—and they’re not going to be able to keep it in their clinic now because they just can’t manage all the controlled substances requirements. So that’s taking a safe, effective, valid medication to facilitate a procedure out of their toolkit.

You mentioned that some hospitals have been running drills—how else are you and other doctors preparing for this law to go into effect?

As a health department, we’re trying to provide as much education as we can. We are directly asking the state Department of Health for clarification on some things that came up.

In New Orleans, our City Council directed the health department to study the impact of this law. We’re setting up a [confidential] reporting form for [health care professionals] because we really do want to continue to educate our policymakers that the concerns are legitimate and they’re done in the spirit of wanting to protect health.

We’re afraid, though, that a lot of this is going to go unreported. Any time that you restrict access, people become fearful, and they just sort of suffer in silence. That doesn’t do anything to improve health care in Louisiana.

Louisiana has one of the highest maternal mortality rates in the country. Are you worried that this law going into effect could affect that?

That’s what we’re all worried about. We are working so hard to reduce the rate of maternal morbidity and mortality. We can identify all kinds of ways that the state could invest its resources to do that. [The] Louisiana Pregnancy[-Associated] Mortality Review committee releases a beautiful report with those recommendations; this was not one of those recommendations.

There’s also the real concern of providers not wanting to practice here. We’re seeing that play out in Idaho, which has restrictive laws, and more than half of their high risk OBs have left the state, according to a report [released in February]. So when a third of our parishes are maternal-care deserts, we can’t afford to lose any more providers. But what we’re being told by medical students and residents is that they don’t really see the benefit to staying and practicing in a state where they are under threat of criminalization for simply providing the highest quality standard of care.

The last time we spoke, the bill was expected to be signed into law. Now it’s going into effect on Oct. 1. How are you feeling?

There’s still a great deal of concern. There’s still a lot of confusion.

The New Orleans Health Department did a learning session with an expert panel of pharmacists and physicians to try to go through the law as best we could and discuss any sort of shared knowledge that we would hope that pharmacists and providers would need to know. I think that was well-received, but there were a lot of questions that we couldn’t answer.

What we’re also hearing is that in other parts of the state, providers are either just learning about this or not aware of it at all. Quite frankly, doctors are very busy—they work very long hours, they don’t necessarily keep up with the legislature, and there’s been very little communication about the act formally to physicians. I think those of us who are in the know are concerned about folks who maybe don’t even really see this coming, and all of a sudden things are going to change on Oct. 1. Everybody is trying really hard to put whatever processes they can in place to mitigate the expected impacts. But no one is feeling really great about it.